Nokea
A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
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A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous, low-pitched gurgling sounds heard over the trachea and bronchi. This finding indicates the presence of secretions or mucus in the larger airways. Crackles (B) are discontinuous, popping sounds heard during inspiration and indicate fluid in the alveoli. Wheezing (C) is a high-pitched whistling sound that occurs when air flows through narrowed airways. Friction rub (D) is a grating or rubbing sound heard during inspiration and expiration, caused by inflammation of the pleural surfaces. The other choices are not consistent with the described findings.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.
A client who is about to undergo hip arthroplasty tells the nurse she is afraid of not receiving adequate anesthesia during the procedure. Which of the following is an appropriate response?
- A. I will call the anesthesiologist right away.
- B. Can you tell me more about this concern?
- C. You have nothing to be concerned about. You have a competent anesthesiologist.
- D. I had a similar procedure and definitely received enough anesthesia.
Correct Answer: B
Rationale: Asking the client to elaborate allows for exploration of their concerns and reassurance through proper information.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.